Form XXXIV

(See Rule - 69)

AN APPLICATION FOR GRANT OF PERMISSION FOR THE INITIAL LOCATION OF A FACTORY

INVOLVING A HAZARDOUS PROCESS OR FOR THE EXPANSION OF SUCH FACTORY

(a) Name and address of the applicant;

(b) Site ownership data;

(c) Revenue details of site such as Survey number, plot number, Allotment/ Registration number,

etc;

(d) Details as to whether the site is classified as forest and if so, whether approval of the Central

Government under Section 5 of the Indian Forests Act, 1927 has been obtained;

(e) Details as to whether the proposed site attracts the provisions of Section3(2) of the

Environment Protection Act, 1986, if so, the nature of the restrictions;

(f) Local authority under whose jurisdiction the site is located;

(g) Documentary evidence of ownership;

(h) Site Plan with clear identification of boundaries total area proposed to be occupied and

showing the following details nearby the proposed site:–

(i) historical monument, if any, in the vicinity;

(ii) names of neighbouring manufacturing units and human habitats, educational and

training institutions, petrol installations, storages of liquefied petroleum gas and other

hazardous substances in the vicinity and their distances from the proposed unit;

(iii) water sources (river, streams, canals, dams and water filtration plants etc.) in the vicinity;

(iv) nearest hospitals, fire-stations, civil defence stations and police stations and their

distances from the proposed unit.

(v) high tension electrical transmission lines, pipelines for water, oil, gas or sewerage ;

(vi) railway lines, roads, stations, jetties gas and other similar installations in the vicinity;

(vii) details of soil conditions and depth at which hard strata can be obtained;

(viii) contour map of the factory showing nearby hillocks and difference in levels; and

(ix) plot plan of the factory showing the entry and exit points roads within, water drains, etc.

(i) Project Report stating the following details :-

(i) a summary of the salient features of the project;

(ii) status of the organisation (government, semi-government, public or private etc.);

(iii) maximum number of persons likely to be employed in the factory;

(iv) maximum requirement of power and water and sources of their supply;

(v) block diagram of the buildings and installations, in the proposed unit; and

(vi) details of the proposed housing colony, hospital, school and other infrastructural facilities.

(j) Organizational structure for proposed manufacturing unit/factory showing :-

(i) organization diagram of proposed enterprise in general, and health, safety and

environment protection departments and their linkage to the operation and technical

department;

(ii) proposed health and safety policy;

(iii) area allocated for treatment of wastes and effluents; and

(iv) percentage of outlay on safety, health and environment protection measures.

(k) Meteorological data relating to the site showing:-

(i) average, minimum and maximum of temperature, humidity and wind velocities during

the previous ten years;

(ii) seasonal variations of wind direction;

(iii) highest water level reached during the floods in the area recorded so far;

(iv) lightening and seismic data of the area.

(l) Communication Links showing:-

(i) availability of telephone/telex/wireless and other communication facilities for outside

communication; and

(ii) proposed internal communication facilities.

(m) Manufacturing Process Information showing

(i) process flow diagram in detail indicating process parameters, e.g. temperature, pressure,

etc. at various stages of manufacturing process;

(ii) brief write-up on process and technology;

(iii) critical process parameters such as pressure build-up, temperature rise and runaway

reconditions;

(iv) other external effects critical to the process having safety implications, such as ingress of

moisture or water, contact with incompatible substances, sudden power failure; and

(v) highlights of the built – in safety/pollution control devices or measures incorporated in the

manufacturing technology.

(n) Information on Hazardous Materials showing:-

(i) raw materials, intermediates, products and by-products and their quantities (enclosed

with material safety data sheet in respect of each hazardous substance);

(ii) main and intermediates, storages proposed for raw materials/ intermediates/ products

(maximum quantities at any time to be stored);

(iii) transportation methods to be used for inflow and outflow of materials, their quantities and

likely routes to be followed; and

(iv) safety measures proposed for handling of materials, internal and external

transportation, and disposal (packing and forwarding of finished products.)

(o) Information of dispersal / disposal of wastes and pollutants showing :-

(i) major pollutants (gas, liquid, solid), their characteristics and quantities (average and at

peak loads);

(ii) quality and quantity of solid wastes generated, methods of their treatment and disposal;

and

(iii) air, water and soil pollution problems anticipated and the proposed measures to control

the same, including treatment and disposal of effluents.

(P) Process Hazards Information along with :-

(i) a copy of the report on Environmental Impact Assessment;

(ii) a copy of the report on Risk Assessment study; and

(iii) Published (open or classified) reports, if any, on accident

(iv) situations / occupational health hazards or similar plants elsewhere (within or outside the

country).

(q) Information of proposed Safety and Occupational Health Measures along with:-

(i) details of fire fighting facilities and minimum quantity of water, carbon dioxide and/or

other fire fighting measures needed to meet the emergency; and

(ii) details of the proposed in house medical facilities.

(r) Information on emergency preparedness showing :-

(i) on-site emergency plan and detailed disaster control measures; and

(ii) proposed arrangements, if any, for a mutual aid scheme with the group of neighboring

factories.

(s) Any other relevant information.

Application mentioned in sub-rule (7) shall be certified by the applicant in the following

manner:-

“I certify that the information furnished above is correct to the best of my knowledge and

nothing of importance has been concealed while furnishing it”.

Signature of the Applicant

Applicant’s full name and address